Clinical Ethics Services Research Articles

The current scenario of clinical ethics in Italy

Background: Italy has seen limited growth and institutionalization of clinical ethics activities in its territory. Only a few observational studies were conducted in Italy to assess the state of the art of clinical ethics services and activities. Aim: We sought to gain a broad and comprehensive understanding of the state of the art as perceived by Italian healthcare institutions and facilities. Methods: We prepared a questionnaire comprising of twelve close-ended and six open-ended questions. We sent it to all Local Healthcare Authorities (Aziende Sanitarie Locali, ASL), all private Scientific Institutes for Research, Hospitalization and Healthcare (Istituti di Ricovero e Cura a Carattere Scientifico, IRCCS), and all hospices throughout Italy. Out of 380 facilities, 90 of them (22.5%) responded to it. Results: All answers revealed interesting data. Among them, the ones that stood are: when asked who they turn to when an ethical dilemma arises, 27.7% of the respondents checked more than two answers, thus showing that there is not one clear and unequivocal body of reference. When asked if there are standard procedures, 55.4% of the respondents declared that there are no standard procedures. Only 4.4% of respondents declared the method of analysis being used. 53.3% responded that their hospital or healthcare facility does not regularly offer training activities and formation to deal with ethical dilemmas Conclusion: The three topics that stand out are a great fragmentation, the need to formalize and establish dedicated services to take care of ethical dilemmas and to offer training and formation to healthcare providers.

Here for the people: The argument for making clinical ethics more patient-centred.

Healthcare organizations aim to provide excellent, patient-centred care. Many departments within a hospital excel in achieving this goal, but clinical ethics service providers would benefit from becoming more patient-centred. This article considers how ethics services can add a patient-facing component to their strategic direction and work portfolio. Through a case example, suggestions to guide ethics service providers in expanding their duties and responsibilities are provided, including consultation with families and education sessions. This reframing would include clarifying the role of ethics within a healthcare organization, making services more accessible to patients, families and the community, as well as engaging with other disciplines to provide well-rounded patient care. While the work currently being done by clinical ethics services is important and ought to be continued, ethics service providers should strive to achieve the goal of improving patient experiences and directly contribute to the excellent care being provided.

Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service – a case study

BackgroundAlthough the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established service, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting.Methods: how the study was performed and statistical tests usedA qualitative case study approach was utilised. The study gathered and analysed data using observations of service committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies.Results: the main findingsAn overarching theme identified in the data was a strong commitment to supporting clinicians facing difficult patient care decisions and navigating difficult discussions with patients and families. Another key theme was the role of the new clinical ethics support service in providing clinicians with a pathway to raise system-wide issues with the organisation Executive. While there was strong clinical engagement, consumer and community participation remained a challenge, as did unresolved governance issues and a need for clearer policy relationship between the service and the organisation.Conclusions: brief summary and potential implicationsConsidering these themes in relation to the national capacity building resources, the study identifies three areas likely to require ongoing development and negotiation. These are: the role of the clinical ethics support service as a link between the workforce and the Executive; the incorporation of consumers and patients; and ethical reasoning. To improve the effectiveness of the service, it is necessary to increase clarity on the service’s role at the governance and policy level, as well as develop strategies for engaging consumers, patients and families. Finally, the capacity of the service to reflect on complex cases may be enhanced through explicit discussions of various different ethical frameworks and ways of deliberating.

The scope of ethical dilemmas in paediatric nursing: a survey of nurses from a tertiary paediatric centre in Australia.

No previous study has provided evidence for the scope and frequency of ethical dilemmas for paediatric nurses. It is essential to understand this to optimise patient care and tailor ethics support for nurses. The aim of this study was to explore the scope of nurses' ethical dilemmas in a paediatric hospital and their engagement with the hospital clinical ethics service. This study used a cross-sectional survey design. Paediatric nursing staff in a tertiary paediatric centre in Australia completed an online survey asking about their exposure to a range of ethical dilemmas and their knowledge of the clinical ethics service. Analysis used descriptive and inferential statistics. Ethical approval was granted from the hospital research committee. The survey was anonymous, and no identifying details of participants were collected. Paediatric nurses experienced a wide range of ethical dilemmas frequently, both in the intensive care and general areas. Knowledge and use of the clinical ethics service was poor and the most frequent challenge for nurses in managing dilemmas was feeling powerless. There is a need to recognise the moral burden of ethical dilemmas for paediatric nurses in order to foster ethical sensitivity, and to provide adequate support to improve care and mitigate nursing moral distress.

Clinical Ethics Concerns of Rural Healthcare Providers

Purpose: This project aimed to identify ethical concerns in rural hospitals and elicit ideas for establishing clinical ethics services to meet needs. Methods: Two-hundred-fifty-six rural physicians were sent an email requesting participation in an electronic survey. Data were entered into Microsoft excel. Findings: Seventy-four (29%) physicians responded; 59% have an ethics committee available to them. Of these ethics committees, 43% are available 24/7. Ethical dilemmas were categorized into themes, with end-of-life care and vulnerable adult concerns identified most commonly. Online group-learning is the preferred training method for ethics education. Thirty-eight percent would likely use a tele-ethics service if available. Conclusions: Providers in rural health systems face unique and complex ethical dilemmas and would likely utilize remote support for complex bioethical situations. Given these findings, the next step is to develop and pilot an ethics service that would include the three traditional roles for a clinical ethics service: policy development, education, and clinical ethics consultation services.

Need For Integration of Clinical Ethics Services as a Global Best Practice in End-of-Life Care in Oncology: Suitability of The Nijmegen Methodology in the Indian Context

Need For Integration of Clinical Ethics Services as a Global Best Practice in End-of-Life Care in Oncology: Suitability of The Nijmegen Methodology in the Indian Context

The need for clinical ethics consultation: a monocentric observational survey study in the intensive care unit (Consul.E.T.I. study)

BackgroundThe current organizational structure of the Italian healthcare system does not include the institutionalization of clinical ethics services.To describe the need for structured clinical ethics consultation services for ICU staff members in the intensive care unit (ICU), a monocentric observational survey study was performed utilizing a paper-based questionnaire.ResultsA total of 73 healthcare professionals (HCPs) responded out of a team of 84 people (87%). The results showed that the need for ethics consultation in the ICU is urgent, the institutionalization of the clinical ethics service is perceived as useful and should be a priority, and the issues on which the HCPs would like ethics consultation to focus are various and belong to “end of life” topics.ConclusionsHCPs believe that the clinical ethicist should become an integral part of ICU healthcare teams, offering consultations similar to the other specialistic consultations carried out in hospitals.

A practical and ethical toolkit for last-minute refusal of anesthetic in children.

Children's fear of a procedure, including the anesthetic, is a common issue that operating theatre staff face. This fear is generally mitigated by preesthetic preparation and information sharing. Last-minute refusal of a procedure creates unique difficulties for the anesthetist and proceduralist. Refusal for a procedure raises issues of whether the dissent is binding, and if not, how best to get the child to theatre without creating moral injury. In this case review of a young adolescent who refuses to go to the operating theatre, we explore practical and ethical options to resolve the situation. We discuss respect for persons (including assent and consent), best interests, truth-telling, harm minimization, and restraint. The importance of a postevent debrief is discussed. We also assess the value of a clinical ethics service with team members embedded in clinical teams.

Managing aggression in hospitals: A role for clinical ethicists

Hospitals are places where patients are unwell, where patients and their families may be upset, confused, frustrated, in pain, and vulnerable. The likelihood of these experiences and emotions manifesting in anger and aggressive behaviour is high. In this paper, we describe the involvement of a clinical ethics service responding to a request to discuss family aggression within a rehabilitation department in a large paediatric hospital in Australia. We suggest two key advantages of involving a clinical ethics service in discussions about how to respond to family aggression. First, the process of ethics deliberation provides an opportunity for clinicians to be involved in the solution by articulating their perspectives, tolerance levels, and general concerns about the effects of family aggression towards staff. Second, supporting clinicians to articulate and identify the impact of parental aggression directly counters the disadvantages of the more blunt zero-tolerance policy response, which is necessarily imposed from the top down.

The COVID-19 Crisis and Clinical Ethics in New York City

The COVID-19 pandemic that struck New York City in the spring of 2020 was a natural experiment for the clinical ethics services of NewYork-Presbyterian (NYP). Two distinct teams at NYP's flagship academic medical centers-at NYP/Columbia University Medical Center (Columbia) and NYP/Weill Cornell Medical Center (Weill Cornell)-were faced with the same pandemic and operated under the same institutional rules. Each campus used time as an heuristic to analyze our collective response. The Columbia team compares consults during the pandemic with the same period during the year prior. The Weill Cornell service describes the phases of the pandemic to depict its temporal evolution and subsequent ethical challenges. Both sites report that the predominant ethical challenges centered around end-of-life decision making, setting goals of care, and medical futility, all complicated by resource allocation questions and the ambiguity of state law under crisis standards of care. The Columbia campus saw a statistically significant increase in ethics consultations provided to Hispanic patients, perhaps reflective of the disproportionate burden of COVID-19 suffered by this demographic. While Weill Cornell and Columbia saw a surge in clinical ethics consultations, the two services assumed a more expansive role than one normally played in institutional life. Serving as intermediaries between frontline clinicians and senior hospital administrators, consultants provided critical intelligence to hospital leadership about the evolution of the pandemic, disseminated information to clinicians, and attended to the moral distress of colleagues who were asked to provide care under truly extraordinary circumstances. The COVID-19 surge in New York City revealed latent capabilities in ethics consultation that may prove useful to the broader clinical ethics community as it responds to the current pandemic and reconceptualizes its potential for future service.

A Futile Use of Futility.

As the rates of intravenous opioid use have increased, so have its associated medical complications, such as endocarditis, and known interventions, such as heart-valve replacements. For many patients, including Jacob, whose case was brought to my psychiatric consult service and to my colleagues in the clinical ethics service, relapse increases the risk of repeat endocarditis and the need for repeat surgical interventions. Previous works have posed the bioethical quandary regarding the responsibilities of a surgeon in these repeat procedures and whether a surgeon may ethically refuse to perform a repeat intervention in a patient who has relapsed. Notions of futility are commonly used to navigate this complex terrain, and they were the focus of the ethics consideration given to Jacob's case, in which surgeons were reluctant to perform valve replacements. In this narrative essay, I interrogate the concept of futility by appealing to its history and variable meanings, and I argue against its relevance in cases like Jacob's. I propose that a more suitable bioethical approach in such cases would consider resource allocation, the sociocultural stigma of addiction, and the interpersonal and narrative factors that make each case unique.

Clinical ethics consultation in the intensive care unit.

The intensive care unit (ICU) represents one of the most ethically burdensome health care settings where uncertainties and disagreements concerning proportionate treatments, goals of care and patients' best interests frequently come up. Clinical ethics consultation (CEC) is a service available to hospital staff, patients and their family members to handle and resolve such moral doubts and conflicts. Considered as the most challenging activity of clinical ethics, it aims to improve the quality of patient care and to increase both health care professionals' familiarity with ethical issues and their competence in identifying and analyzing moral problems. Data concerning CEC in ICUs reveal how it reduces provision of disproportionate treatments, hospital costs and conflicts in addition to producing user satisfaction. First, we show what use CEC can have in an ICU, especially in the process of shared decision making. Then, we analyze two attitudes which may prevent CEC from being fully integrated in the health care system. Lastly, we illustrate the advantages of implementing a clinical ethics service where the full spectrum of ethics support activities are ensured on an ongoing basis.

The practice of balancing in clinical ethics case consultation

Models for clinical ethics case consultation often make reference to ‘balancing’ or ‘weighing’ moral considerations, without further detail. In this paper, we investigate balancing in clinical ethics case consultation. We suggest that, while clinical ethics services cannot resolve ongoing deep philosophical debates about the nature of ethical reasoning, clinical ethicists can and should be more systematic and transparent when balancing considerations in case consultations. We conceptualise balancing on a spectrum from intuitive to deliberative, and argue that good balancing in case consultation involves articulating reasons for giving something more or less weight. We develop a framework of four practical strategies for better balancing in clinical ethics case consultation: intuitions as a launchpad, drilling down, pairwise comparison and group deliberation.

Challenges and Opportunities in Clinical Ethics with the Implementation of Korea’s End-of-Life Act

This paper examines the possible impacts of the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life in Korea (Korea’s end-of-life act), legislated in 2016, on the development of hospital ethics committees and clinical ethics consultation services in South Korea. Clinical ethics in Korea has not made much progress in comparison to other subdisciplines of biomedical ethics. While the enactment of this law may give rise to beneficial clinical ethics services, it is possible that customary practices and traditional authorities in Korean society will come into conflict with the norms of clinical ethics. This paper examines how the three main agents of Korean society—family, government, and medical professionals—may clash with end-of-life stage norms in clinical ethics, thus posing obstacles to the development of hospital committees and consultation services. A brief outline of what lies ahead for the progress of clinical ethics practice is explored.

Role of Clinical Ethics Support Services in End-of-Life Care and Organ Transplantation

At times, clinical expertise may not be sufficient to find a way out of a moral impasse, especially in the context of end-of-life and organ transplantation decisions. Advances in medical knowledge and technology, and highly pluralistic and multicultural societies, have led to the emergence of new ethical problems in daily clinical practice along with the need to manage them in a prompt and effective manner. Clinical ethics developed in the late 1970s and early 1980s in North American health care contexts with the aim of identifying, analyzing, and attempting to resolve ethical conflicts and dilemmas at the patient’s bedside. At present, only a few regions in Italy have established clinical ethics committees, and Italy may count on a very small number of clinical ethics services fully devoted to ethics case consultation, guidelines development, and the education of health care providers and citizens. Despite this situation, one has to acknowledge both the increasing request for ethics support coming from health care providers who experience an “ethical vacuum” in the Italian health care system and the cultural change that is affecting Italy nowadays. By highlighting clinical examples and sharing experiences, we show and encourage the potential benefits of establishing clinical ethics services in Italian health care contexts.

Objectives and outcomes of clinical ethics services: a Delphi study

ObjectivesTo explore the objectives and outcomes most appropriate for evaluating clinical ethics support services (CESs) in the USA.MethodsA three-round e-Delphi was sent to two professional medical ethics listservs (Medical College...

Clarifying a Clinical Ethics Service’s Value, the Visible and the Hidden

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un-Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.

Ethically permissible inequity in access to experimental therapies

Clinical ethics services are increasingly receiving case referrals regarding requests for access to experimental therapies. Sometimes, patients or families seek access to an experimental therapy that has not been subsidised by any government scheme, and for which no local clinical trial is underway. All else being equal, a patient may benefit from receiving an experimental therapy without making any other patient worse off. However, within public healthcare systems, treating only one patient with an experimental therapy, when others might also benefit from it, evokes a troubling sense of inequity. In this paper, I examine the relevance of Pareto principles and the ‘levelling down’ objection to ethical deliberation about patient or family-initiated requests for experimental therapies. While facilitating access to an experimental therapy may benefit a patient without making any other patients worse off, this does not dispel ethically relevant considerations concerning equity. When deliberating about cases involving inequity, clinicians and hospitals must balance directly improving the position of individual patients with avoiding contributing to or tolerating avoidable inequities. I argue that inequity in access to experimental therapies can be ethically permissible, but only if satisfies two conditions: firstly, the decision to provide one patient and not others with a promising experimental therapy must have a strong likelihood of contributing to future equity; and secondly, the inequity must be exercised in a way that shows respect for other patients who are not equally able to access the therapy in question.

Redundancy or Value-Added? Ethics Consults in Hospitalized Patients with Palliative Medicine Involvement (QI738)

1.Describe services typically provided by clinical ethics services and the ways in which these overlap with reasons for palliative medicine consults.2.Discuss ways in which incorporation of ethical principles in palliative medicine notes and recommendations may provide additional reassurance to primary teams. Many academic medical centers have both palliative medicine (PM) and clinical ethics teams; there is overlap in the services provided by these teams. We sought to better understand what services are provided by clinical ethics consultations not currently offered by PM. We performed a retrospective chart review on all patients seen by both PM and clinical ethics during a single admission over a two-year period. Assessment and recommendations from clinical ethics notes were abstracted verbatim. Two members of the study team used MAXQDA software to independently code themes present in the clinical ethic notes; they met to discuss and reach consensus on codes. We identified 84 patients seen by both palliative medicine and clinical ethics during a single admission over a two-year period. The three most common issues addressed by the ethics consult were goals of care, medical surrogacy, and providing support. Specific issues relating to goals of care included: patients refusing medical treatment or wanting to return home, code status discrepancies, and concerns around withdrawing or continuing life-sustaining treatment. Surrogacy issues addressed included: assistance with identifying an appropriate surrogate, concerns about the surrogate, decision making when no surrogate is available, and guardianship. There was specific language regarding legal or ethical recommendations in 32/84 patients (38%). We observed frequent explicit use of ethical principles in ethics notes, such as autonomy and beneficence, which were not included in PM notes. We noted that many of the services provided by clinical ethics are similar to those offered by PM including assistance with goals of care conversations and advice regarding surrogacy. However, use of language such as “ethically permissible” or “legally permissible,” accompanied by moral reasoning, may be delivering additional reassurance to medical teams not currently provided by PM. PM clinicians may be able to further assist primary teams by using ethical reasoning in their assessments and recommendations.

Research ethics oversight in Norway: structure, function, and challenges

BackgroundWhile the development and evaluation of clinical ethics services in Norway has been recognized internationally, the country’s research ethics infrastructure at times may have been less well developed. In 2016, media interest in the controversial nature of some health services research and pilot studies highlighted gaps in the system with certain types of research having no clear mechanisms through which they may be given due independent consideration. It is not clear that new legislation, implemented in 2017, will address this problem.SummaryWe explore relevant law, committee scope, and the function of the system. We show that 1) Norwegian law provides for ethics assessment for all forms of health research; 2) regional RECs in Norway might not have always enforced this provision, considering some interventional health services research to be outside their remit; and 3) Norwegian law does not explicity provide for local/university RECs, meaning that, in practice, there may be no readily accessible mechanisms for the assessment of research that is excluded by regional RECs. This may include health services research, pilot studies, and undergraduate research. New 2017 legislation has no effect on this specifically but focuses on institutions regulating researcher activity. This may place researchers in the difficult situation of on one hand, needing to hold to recognized ethical standards, while on the other, not readily having access to independent committee scrutiny to facilitate consistent operation with these standards.ConclusionTo support researchers in Norway and to protect the public, it may be necessary either to widen the regional RECs’ remit or to make legislative alterations that permit and do not discourage the existence of local RECs.